In this blog post, I will be discussing the SciF E3067 form. This is a form that is used to document the results of an evaluation for a specific scientific inquiry. The purpose of this form is to provide information on the investigation, the methods used, and the findings of the study. The SciF E3067 form can be used by researchers and scientists to document their findings, and it can also be used as a tool for quality assurance. In my previous blog posts, I have discussed the different types of scientific forms that are used in research, so if you are interested in learning more about those forms, I would recommend checking out those posts.
You'll find it useful to know the amount of time you'll need to complete this scif e3067 form and exactly how lengthy this document is.
Question | Answer |
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Form Name | Scif E3067 Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | scif rev, form 3067 fill, scif e3067, e3067 rev |
State of California
EMPLOYER'S REPORT
OF OCCUPATIONAL INJURY OR ILLNESS
STATE COMPENSATION INSURANCE FUND
Telephone: (888)
OSHA
Case No.
Fatality
Any person who makes or causes to be made any |
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NOTICE: California law requires employers to report within five days of knowledge every occupational injury or illness |
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knowingly false or fraudulent material statement |
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which results in lost time beyond the date of the incident OR requires medical treatment beyond first aid. If an employee |
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or material representation for the purpose of |
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subsequently dies as a result of a previously reported injury or illness, the employer must file within five days of knowledge |
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obtaining or denying workers' compensation |
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an amended report indicating death. In addition, every serious injury, illness, or death must be reported immediately by |
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benefits or payments is guilty of a felony. |
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telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health. |
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1. FIRM NAME |
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DIVISION |
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1a. Policy Number |
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Please do |
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not use this |
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Column |
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2. MAILING ADDRESS (Number and Street, City, Zip) |
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2a. Phone Number |
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Case Number |
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3. LOCATION, if different from Mailing Address (Number, Street, City and Zip) |
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3a. Location Code |
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Ownership |
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4. NATURE OF BUSINESS; e.g., Painting contractor, wholesale grocer, sawmill, hotel, etc. |
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5. STATE UNEMPLOYMENT INSURANCE |
Industry |
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E |
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ACCT. NO. |
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6. TYPE OF EMPLOYER |
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Occupation |
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PRIVATE |
STATE |
COUNTY |
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CITY |
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SCHOOL DIST. |
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OTHER GOVERNMENT - SPECIFY ____________________________________ |
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7. DATE OF INJURY / ONSET OF ILLNESS |
8. TIME INJURY/ILLNESS OCCURRED |
9. TIME EMPLOYEE BEGAN WORK |
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10. IF EMPLOYEE DIED, DATE OF DEATH |
Sex |
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(mm/dd/yy) |
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________ A.M. |
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________ P.M. |
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(mm/dd/yy) |
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________ A.M. ________ P.M. |
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11. UNABLE TO WORK FOR AT LEAST ONE |
12. DATE LAST WORKED (mm/dd/yy) |
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13. DATE RETURNED TO WORK |
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14. IF STILL OFF WORK, CHECK THIS |
Age |
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FULL DAY AFTER |
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NO |
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(mm/dd/yy) |
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BOX |
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DATE OF INJURY? |
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15. PAID FULL DAY'S WAGES FOR DATE OF |
16. SALARY BEING CONTINUED? |
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17. DATE OF EMPLOYER'S KNOWLEDGE/ |
18. DATE EMPLOYEE WAS PROVIDED |
Daily hours |
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INJURY OR LAST |
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NO |
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NOTICE OF INJURY/ILLNESS (mm/dd/yy) |
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CLAIM FORM (mm/dd/yy) |
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DAY WORKED? |
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19. SPECIFIC INJURY/ILLNESS AND MEDICAL DIAGNOSIS if available, e.g., Second degree burns on right arm, tendonitis on left elbow, lead poisoning. |
19a. BODY PART AFFECTED |
Days per Week |
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R |
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20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Address) |
20a. ZIP |
20b. COUNTY |
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21. ON EMPLOYER'S PREMISES? |
21a. WAS ANOTHER PERSON |
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Y |
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YES |
NO |
RESPONSIBLE? |
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Weekly Hours |
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YES |
NO |
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22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g., Shipping department, machine shop. |
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23. OTHER WORKERS INJURED OR ILL IN THIS EVENT? |
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R |
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YES |
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NO |
Weekly Wage |
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24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g., Acetylene, welding torch, farm tractor, scaffold. |
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L |
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25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g., Welding seams of metal forms, loading boxes onto truck. |
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L |
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N |
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E |
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26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURY/ILLNESS, |
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e.g., Worker stepped back to inspect work and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF NECESSARY. |
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Nature of Injury |
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27. NAME AND ADDRESS OF PHYSICIAN (Number, Street, City, Zip) |
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27a. Phone Number |
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28. HOSPITALIZED AS AN INPATIENT OVERNIGHT? |
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YES If yes, then, NAME AND ADDRESS OF HOSPITAL (Number, |
28a. Phone Number |
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Part of body |
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Street, City, Zip) |
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(Number, Street, City, Zip) |
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29. Employee treated in Emergency Room? |
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YES |
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NO |
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ATTENTION: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while |
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the information is being used for occupational safety and health purposes. See CCR Title 8 14300.29 |
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Source |
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Note: Shaded boxes indicate confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2.* |
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30. EMPLOYEE NAME |
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31. SOCIAL SECURITY NUMBER |
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32. DATE OF BIRTH (mm/dd/yy) |
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Event |
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33. HOME ADDRESS (Number, Street, City, Zip) |
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33a. PHONE NUMBER |
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34. SEX |
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35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers) |
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36. DATE OF HIRE (mm/dd/yy) |
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Secondary |
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MALE |
FEMALE |
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Source |
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Y |
37. EMPLOYEE USUALLY WORKS |
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37a. EMPLOYMENT STATUS |
disabled |
unemployed |
37b. UNDER WHAT CLASS CODE OF YOUR |
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regular, |
retired |
on strike |
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POLICY WERE WAGES ASSIGNED? |
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hours |
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total |
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Extent of Injury |
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______per day |
________per week _________weekly hours |
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temporary |
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seasonal |
other |
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38. GROSS WAGES/SALARY |
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39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g., tips, meals, overtime, |
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$ ___________________ per ___________________ |
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bonuses, etc.)? |
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YES |
NO |
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40. Number of employees on most recent policy inception or renewal date in effect at time of injury. |
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Date (mm/dd/yy) |
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Completed By (type or print) |
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Signature & Title |
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* Confidential information may be disclosed only to the employee, former employee, or their personal representative (CCR Title 8 14300.35), to others for the purpose of processing a workers' compensation or other insurance claim: and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 14300.30). CCR Title 8 14300.40 requires provision upon request to certain state and federal workplace safety agencies.
SCIF e3067 (REV. |
FILING OF THIS REPORT IS NOT AN ADMISSION OF LIABILITY. A CLAIM FORM MUST BE GIVEN TO THE INJURED WORKER WITHIN ONE |
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WORKING DAY OF YOUR KNOWLEDGE OF OCCUPATIONAL INJURY OR ILLNESS WHICH RESULTS IN LOST TIME OR MEDICAL TREATMENT. |